The utility of a modified Kendi-Macy framework for SUID prevention

Gina Lowell, MD, MPH
Rojin Ahadi, MPH
Felicia Clark, D-ABMDI
Christie Lawrence, DNP, RNC-NIC, APN/CNS
Meredith Reynolds, MD
Kyran Quinlan, MD, MPH

Sudden Unexpected Infant Death (SUID) takes the lives of ~3500 infants each year in the United States and has seen virtually no progress in prevention for more than 2 decades. SUID risk is tied closely to poverty. The relationship between SUID risk and poverty is multilayered and complex which hinders the generation of simple and effective prevention programs. In 2023, an Injury Equity Framework was proposed to aid careful review of child deaths and injuries to generate prevention recommendations.

Beginning in July 2023 the Kendi-Macy Injury Equity Framework was applied to review SUID in Cook County, Illinois which includes Chicago where racial disparity of SUID is highest among the most populous cities in the country. The original framework was tailored to work best for SUID and for a resource-limited setting. The Cook County SUID Case Registry team used this process in monthly meetings to carefully review how social influences of health directly contributed to each death and to generate practical SUID prevention recommendations addressing contributing factors in high-risk populations of Cook County. For each death, the grid of the matrix was filled with contributions from all team members. Recommendations were generated and efforts to act on these recommendations were taken.

From July 2023 to May 2025, a total of 64 SUID were reviewed using the Cook County-modified injury equity matrix (IEM). IEM review surfaced 52 ideas among 5 categories of further pursuit: 1) data discovery (7), 2) messaging lessons (14), 3) advocacy opportunities (8), 4) actionable prevention (19), and 5) policy recommendations (4). Of these ideas, all data discovery was completed; 4/8 advocacy opportunities were pursued; 13/19 prevention programming efforts were completed or are ongoing, and 2/4 policy recommendations were adopted. Data discovery included further analysis of SUID related to temporary stay situations, domestic violence, substance use history, and child welfare involvement. Prevention programming included outreach to relevant support agencies (e.g. domestic violence, substance use, shelters), safe sleep training tailored to local agency needs (e.g. WIC/home visiting/doulas), and a combined SIDS and DV awareness resource fair. Adopted policy recommendations included developing Guidance for Safe Sleep in Shelters, including advocacy to ensure infants in Chicago shelters have a bassinet or portable crib for sleep; and a collective advocacy effort eliminating the prenatal visit requirement for families to receive a portable crib from a Medicaid managed care plan. Pending policy recommendations include work to require hotels/motels to provide safe sleep spaces for infants, and advocacy to have all SUID in Cook County receive equitable evaluation by the Illinois Department of Children and Family Services. At times, IEM review generated questions that led to rich discussion without an actionable outcome (4).

The Kendi-Macy framework modified for SUID was fruitful to identify innovative prevention measures to address the complex interplay between poverty and SUID risk.

1. SUID review using a methodical approach deepens understanding of the association between poverty and SUID risk.
2. A multidisciplinary review team allows for diverse perspectives and generates multiple avenues to further SUID prevention.
3. SUID surveillance is enhanced by methodical case review.